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▸ Discuss the current understanding of the interactions between multiple sclerosis and pregnancy and their implications for reproductive counseling, and discuss the issues related to disease-modifying therapy and therapy of acute exacerbations of multiple sclerosis during pregnancy and lactation

▸ Explain issues regarding the management of women with epilepsy and pregnancy, including preconception planning, antiepileptic drug effects on the exposed offspring, and consequences of seizures during pregnancy, with an emphasis on counseling and risk management

▸ Identify the ways in which the physiologic changes of pregnancy affect risk of ischemic and hemorrhagic stroke, and discuss an approach to the diagnosis and treatment of ischemic and hemorrhagic stroke in pregnancy and the puerperium

▸ Outline the most common peripheral neuropathic disorders in pregnancy with a focus on clinical recognition, diagnosis, and treatment

▸ Analyze available information regarding expectations and management for patients with myasthenia gravis during childbearing years, pregnancy, and postpartum

▸ Diagnose and manage primary and secondary headaches that may occur during pregnancy and postpartum

▸ Describe movement disorders that occur during pregnancy, the treatment of preexisting movement disorders, and the influence the pregnant state has on movement disorder symptoms

▸ Evaluate and treat neuro-ophthalmic disorders in pregnant patients

▸ Summarize the available literature on reproductive issues in women with multiple sclerosis and provide sound, objective counseling to facilitate well-informed, autonomous decision making by patients

aDr Feske has received royalties from Elsevier for his role as editor of Office Practice of Neurology, 2nd Edition, and receives research support from the National Institute of Neurological Disorders and Stroke.

Professor of Neurology; Chief, Division of Epilepsy and Electroencephalography, Hofstra North Shore–LIJ School of Medicine, Great Neck, New York

aDr Harden has received personal compensation for activities with GlaxoSmithKline; Lundbeck; UCB SA; and Upsher-Smith Laboratories, Inc. Dr Harden has served in an editorial capacity for UpToDate and received research support from the Epilepsy Therapy Project.

aDr Klein receives financial compensation for serving on the editorial board of the Journal of Neuroimaging and AccessMedicine Neurology, and royalties from McGraw-Hill for Adams and Victor’s Principles of Neurology.

bDr Klein reports no disclosure.

E. Anne MacGregor, MB BS, MD, FFSRH, MICR

Associate Specialist, Barts Sexual Health Centre, St Bartholomew’s Hospital; Honorary Professor, Centre for Neuroscience and Trauma, Blizard Institute of Cell and Molecular Science, Barts and the London School of Medicine and Dentistry, London, England, United Kingdom

aDr Miyasaki has served as a speaker or on advisory boards for Novartis Corporation and Teva Pharmaceuticals. Dr Miyasaki has received research support from the Canadian Agency for Drugs and Technologies in Health, the Canadian Institute for Health Research, the Michael J. Fox Foundation for Parkinson’s Research, the National Center for Complementary and Alternative Medicine, the National Parkinson Foundation, the NIH, the Ontario Drug Benefits Program, and the Ontario Ministry of Health and Long-Term Care. The Movement Disorders Centre at Toronto Western Hospital has received research support from Teva Pharmaceuticals.

bDr Morgan-Followell discusses the unlabeled use of disease-modifying therapies during attempts at conception and during pregnancy.

Jacqueline A. Nicholas, MD, MPH

Assistant Professor of Neurology, Division of Neuroimmunology, The Ohio State University Medical Center, Columbus, Ohio

aDr Nicholas’ fellowship is funded through a Sylvia Lawry Physician Fellowship grant from the National Multiple Sclerosis Society, and she receives additional funding for clinical research from the National Multiple Sclerosis Society as an assistant professor.

bDr Nicholas discusses the unlabeled use of disease-modifying therapies during attempts at conception and during pregnancy.

Laura B. Powers, MD, FAAN

Dr Powers is retired from private practice.

aDr Powers serves as ICD-9-CM Advisor for the Coding Subcommittee of the AAN Medical Economics and Management Committee and serves in an editorial capacity for Neurology: Clinical Practice.

aDr Singhal has served as a consultant for Biogen Idec and as a medical expert witness in cases of stroke. Dr Singhal’s spouse holds stock or stock options greater than 5% of the company or greater than $10,000 in value in Biogen Idec and Vertex Pharmaceuticals Incorporated. Dr Singhal has received research support from the National Institute of Neurological Disorders and Stroke, and his institution has received research support from Pfizer Inc and PhotoThera, Inc, for clinical trial participation.

Continuum: Lifelong Learning in Neurology® is designed to help practicing neurologists stay abreast of advances in the field while simultaneously developing lifelong self-directed learning skills. In Continuum, the process of absorbing, integrating, and applying the material presented is as important as, if not more important than, the material itself.The goals of Continuum include disseminating up-to-date information to the practicing neurologist in a lively, interactive format; fostering self-assessment and lifelong study skills; encouraging critical thinking; and, in the final analysis, strengthening and improving patient care.Each Continuum issue is prepared by distinguished faculty who are acknowledged leaders in their respective fields. Six issues are published annually and are composed of review articles, case-based discussions on ethical and practice issues related to the issue topic, coding information, and comprehensive CME and self-assessment offerings, including a self-assessment pretest, multiple-choice questions with preferred responses, and a patient management problem. For detailed instructions regarding Continuum CME and self-assessment activities, visit aan.com/continuum/cme.The review articles emphasize clinical issues emerging in the field in recent years. Case reports and vignettes are used liberally, as are tables and illustrations. Video material relating to the issue topic accompanies issues when applicable.The text can be reviewed and digested most effectively by establishing a regular schedule of study in the office or at home, either alone or in an interactive group. If subscribers use such regular and perhaps new study habits, Continuum's goal of establishing lifelong learning patterns can be met.

Author Information

Relationship Disclosure: Dr Yerby serves on the speakers bureaus for Lundbeck and Supernus Pharmaceuticals, Inc. Dr Powers serves as ICD-9-CM Advisor for the Coding Subcommittee of the AAN Medical Economics and Management Committee and serves in an editorial capacity for Neurology: Clinical Practice.

Unlabeled Use of Products/Investigational Use Disclosure: Drs Yerby and Powers report no disclosures.

Accurate coding is an important function of neurologic practice. This contribution to CONTINUUM is part of an ongoing series that presents helpful coding information along with examples related to the issue topic. Tips for diagnosis coding, Evaluation and Management coding, procedure coding, or a combination are presented, depending on which is most useful for the subject area of the issue.

INTRODUCTION

The evaluation and management of epilepsy during pregnancy is complex, requiring coordinated care between the neurologist and obstetrician.1,2 Given the complexity of these conditions, the American Academy of Neurology has developed guidelines to assist neurologists in developing comprehensive plans for such patients. The potential for liability is significant when managing women with epilepsy immediately before and during pregnancy; therefore, the following issues will need to be covered in the medical record.

* Education of the patient with a clear statement of the risks of seizures and antiepileptic medication, and the use of folic acid.

* Education of the obstetrician with review of the risks, one’s plans to mitigate them, and a plan for the obstetrician to treat acute maternal seizures during labor and delivery.

* Verification of the diagnosis of epilepsy. Not all seizures are epilepsy, and one needs to be able to support the diagnosis.

* Considerations of alternative treatments from among the various antiepileptic drugs (AEDs).

* Consideration of comorbidities (women with epilepsy have higher than expected rates of depression, anxiety, and migraine, as well as eclampsia).

* Determination of the most effective AED and plasma concentration range for an individual patient.

* Development of a plan for monitoring AED levels during pregnancy and the postpartum period.

PROPER EVALUATION AND MANAGEMENT CODING

Epilepsy patients, particularly when pregnant, require a level of complexity and extra time spent in their care that qualifies them for higher levels of medical decision making and increased levels of service. This is also true for patients with other neurologic diseases affecting or affected by the pregnancy. The documentation for the level of service must meet Current Procedural Terminology (CPT) requirements for the “bullet” method, be based on time, or make use of prolonged service codes as discussed in previous issues of CONTINUUM.3

DIAGNOSIS CODING

The Official Guidelines for Coding and Reporting for both International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) have special sequencing instructions for coding of patient visits during pregnancy.4,5 A code designating the pregnancy is always listed first unless the condition for which the patient is being evaluated has no effect on the pregnancy or is not affected by the pregnancy in any way. Both classifications have codes specifically created for use with neurologic conditions complicating or affected by pregnancy.

ICD-9-CM Codes Used in Visits for Patients With Neurologic Conditions

(In the following table, x is a placeholder for the fifth digit, to be coded as follows: 0 = unspecified as to episode of care or not applicable; 1 = delivered, with or without mention of antepartum condition; 2 = delivered, with mention of postpartum complication; 3 = antepartum condition or complication; 4 = postpartum condition or complication.)

Any condition classifiable to 430-434, 436-437 occurring during pregnancy, childbirth, or the puerperium or specified as puerperal

V26.49 Other procreative management counseling and advice

V22.2 Pregnant state, incidental

Code this following the neurologic condition code when the condition is not affected by or does not affect the pregnancy

ICD-10-CM will be used for diagnosis coding in the United States beginning October 1, 2014. In ICD-10-CM, the trimester and delivery status is captured in codes, but not always at the same character position.

CASE EXAMPLES

Coding Case 1

A 24-year-old woman with a history of localization-related epilepsy and rare secondary generalization controlled on levetiracetam, came for consultation (requested by her internist) and advice on whether she should remain on or change her medication, since she had recently married and was planning to have children. She did not currently have an obstetrician.

After confirming her diagnosis, the neurologist reviewed the risks of pregnancy and epilepsy in terms of both maternal seizures and antiepileptic medication–related risk to the fetus. The neurologist also discussed ways to minimize risks and plans for monitoring her levetiracetam during pregnancy and the postpartum period, as well as for acute seizure management, and reviewed the information on breast-feeding. This visit took an hour. The documentation met criteria for comprehensive history and physical exam.

The CPT Evaluation and Management code appropriate for this visit, given the high level of medical complexity, would be 99245 if the patient’s insurance or other payer allows use of consult codes. If not, then the new-patient code 99205 is appropriate. Prolonged service codes are not appropriate here because the “typical time” for 99245 is 80 minutes and for 99205 is 60 minutes. Prolonged service must be at least 30 minutes beyond the “typical time” for a visit code. The ICD-9-CM codes would be 345.40 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy) and V26.49 (Other procreative management counseling and advice). The corresponding ICD-10-CM codes for use after October 1, 2014, are G40.209 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus) and Z31.69 (Encounter for other general counseling and advice on procreation).

Coding Case 2

A 28-year-old pregnant woman with epilepsy was admitted to the hospital for non-neurologic complications of the second trimester of her pregnancy. She had a seizure while hospitalized, and a neurologist who had not seen her before was asked to consult. Her epilepsy had previously been well controlled. After determining that she did not have eclampsia, the neurologist established her epilepsy type as complex partial with secondary generalization, evaluated her anticonvulsant medication, and made dose adjustments. The neurologist then counseled the patient and her family about seizures in pregnancy, effects of the seizure and medications on her fetus, and developed a treatment plan for managing potential acute seizures during the remainder of her pregnancy. The documentation met criteria for a detailed history and physical examination. The visit took 85 minutes, and 55 minutes were spent in counseling and coordination of care (times documented).

Although the history and physical examination did not fulfill the requirements for a level five consultation (99245) or new patient (99205), the time spent in counseling and coordination of care does. The ICD-9-CM codes would be 649.43 (Epilepsy complicating pregnancy, childbirth, or the puerperium) and 345.40 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, without mention of intractable epilepsy). The ICD-10-CM codes will be O99.352 (Diseases of the central nervous system complicating pregnancy, second trimester) and G40.209 (Localization-related epilepsy and epileptic syndromes with complex partial seizures, not intractable, without status epilepticus).

Let us say, for example, that the neurologist in this case did determine that the patient’s recent seizure was due to eclampsia. The first-listed ICD-9-CM code would be 642.63 (Eclampsia, antepartum condition or complication). In ICD-10-CM, the first-listed code would be O15.02 (Eclampsia in pregnancy, second trimester). The epilepsy code would be listed secondarily, as this condition would also be necessarily addressed.

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